7-14: Pelvic Fracture

Clinical Summary

Pelvic fractures are most often the result of motor vehicle crashes or falls and are fraught with complications. The pelvis should be regarded as a ring; identification of one fracture or dislocation should prompt surveillance for another. Trauma to the genitourinary (GU) tract is suggested by blood at the urethral meatus, a high-riding prostate, gross hematuria, or scrotal hematoma. Spinal nerves, the lumbosacral plexus, the sacral plexus, and the major lower extremity peripheral nerves, such as the sciatic, femoral, obturator, and pudendal nerves, are found in close proximity to the pelvis. A neurologic examination of the lower extremities should include a rectal examination to assess tone. The iliac arteries, veins, and their branches are also enveloped by the bony architecture of the pelvis, and severe hemorrhage is a common complication. While ecchymosis of the anterior abdominal wall, flank, sacral, or gluteal region suggests hemorrhage, there may be no outward signs of a severe hemorrhage. Blood found during rectal or vaginal examination may indicate a puncture wound from the fracture.

The overall mortality in patients with a pelvic fracture is 8%. Mortality rates are higher in men, elderly, and in patients who present in shock.

Management and Disposition

An AP x-ray of the pelvis may serve as a screening tool or a rapid confirmation of suspected major injury. Contrast-enhanced CT of the abdomen and pelvis will be required for known fractures to identify active bleeding and associated injuries. A retrograde urethrogram may also be necessary if a urethral injury is suspected. Angiography by interventional radiology with selective embolization may be performed to control arterial bleeding. In the face of a widened pubic symphysis or “open book” pelvic fracture and continued hemodynamic instability, orthopedic consultation for emergent external fixation can help to reduce blood vessel tension and reduce hemorrhage.

Pearls

1. A commercial pelvic binder or a sheet secured around the pelvis and extend below the greater trochanters, may be used to temporarily stabilize pelvic fractures.

2. Posterior pelvic fractures are more likely to result in neurovascular injuries, while anterior pelvic fractures are more likely to cause urogenital injuries.

3. FAST sensitivity is 26% in detecting hemoperitoneum in patients with pelvic fractures. A negative FAST is therefore inadequate to eliminate the need for laparotomy in an unstable patient.